Background: Substance abuse is clearly associated with criminal recidivism among offenders with and without mental disorder. Treatment for substance abuse correlates with lower rates of re-offending among participants in outpatient-based as well as institution-based substance abuse treatment programs. However, for offenders with mental disorder, research on the possible preventive effect of substance abuse treatment on criminal recidivism is sparse. This paper reports from on an ongoing naturalistic and prospective interview study on the relationship between post-release outpatient substance abuse treatment and re-offending. Methods: The Stockholm county sample comprises 246 offenders of both genders subjected to a forensic psychiatric assessment, who screened positive for substance abuse problems. Eighty-five percent (n=210) agreed to participate in the study. Baseline data and follow-up interview data, collected immediately on release from incarceration (prison/forensic hospital) and 6 and 12 months later, include self-reported substance abuse, treatment involvement and criminality. By February 2010, data will be available from the first follow-up for 150 participants, from the second follow-up for 80 individuals and from the third follow-up for 10 subjects. Results and conclusions: The focus of the presentation will be recidivism comparisons between substance abuse treatment utilizers and those who decline treatment. Data on ongoing levels of substance abuse, mental health problems and offending will serve as dependent variables. Additional analyses will present perceived benefit from and reasons for accepting or rejecting treatment.

Introduction: Substance abuse is associated with criminal recidivism. Substance abuse treatment has been found to correlate negatively with re-offending among treatment utilizers. However, for offenders with mental health problems and substance abuse, research on how substance abuse treatment affects re-offending is sparse. Objectives: The study aimed to examine the relationship between self-reported outpatient-based substance abuse treatment and self-reported a) re-offending, b) substance use and c) psychiatric problems among offenders with mental health and substance use problems. Methods: Data were gathered from a naturalistic follow-up study with 208 participants, subjected to a court-ordered psychiatric assessment. This analysis covers 91 individuals who were followed-up after an average study period of 17 months. Among these, 68% had been sentenced to institutional imprisonment or forensic psychiatric care. Results: Offences, substance use and psychiatric problems declined between baseline and follow-up. However, the reduction was not associated with self-reported treatment utilization. Among participants who were sentenced to non-institutional corrections, more individuals had utilized outpatient-based treatment compared to individuals who were sentenced to imprisonment or forensic psychiatric care. Conclusions: A definitive conclusion about the effect of treatment is difficult to draw. For instance, self-reported data may not reflect actual treatment consumption. However, one interpretation is that participants naturally recovered over time. Institutional correction might also have resulted in positive outcomes equivalent to outpatient-based treatment.

Aim: The overall aim of this thesis was to explore the manner in which user knowledge and user perspectives can be included and supported in shared decision making (SDM) in mental health services.

The thesis consists of four studies. Study I explored what needs service users identify to participate in deliberative processes and decision making in their care. Study II examined how a decision support tool (DST) for SDM can be designed to enhance service users’ ability to have active and meaningful roles in SDM. Study III investigated barriers and facilitators associated with the implementation of a web-based DST designed to provide a concrete structure to support SDM. In study IV, a theoretical analysis was performed to elucidate the barriers associated with user knowledge being expressed and legitimized in decision-making processes.

Methods: A key feature of the project involved a process of exploring decisional and informational needs and of developing, testing and implementing a DST for SDM. Qualitative data have been collected through focus group and individual interviews with service users and service providers, usability testing with service users and checklists.

Findings: The findings show a number of characteristics specific to the mental health service context that need to be considered when developing support for SDM. Decisions were often complex and found to encompass a number of life domains. Issues related to social context and individual recovery highlighted the necessity to include the knowledge perspectives of service users throughout decision processes. In response, phases for preparation and follow-up was emphasized in the DST. The results indicate that supportive structures are required for service users to express their knowledge perspectives and for providers to include them in their decision-making. Moreover, existing barriers related to organizational structures and to power differentials need to be addressed.

Conclusions and implications: A DST specifically designed for the mental health context, that methodically invites service users to participate in each phase of the decision-making process might function as a guiding structure to validate service users as knowledgeable agents.

Introduction. Psychiatric intensive care units (PICU) are rarely described since it is secluded from external insight. At the same time, it is highly intensive since staff and patients interact around the clock in the most acute phase of psychiatric illness. The PICUs admit patients who are considered extremely unmanageable within psychosis units or acute psychiatric wards, and who often demonstrate aggressive or other forms of severe behaviors.

Objectives. This raises the question: What is going on in these units and what constitutes nursing care?

Methods. Spradley's 12-step ethnographic methodology was applied. Data was collected through more than 200 hours of field work on three PICUs including 16 hours of formal interviewing and numerous of informal interviews; data also consisted of writing memos and field notes. The field work aimed to understand the staff member's way of interact with the patients and what they did to care for these patients who was considered as unmanageable.

Results. The findings presented here describe how and when nursing care is provided in PICUs. The findings are presented in relation to themes, as these emerged within the psychiatric intensive nursing care. Six themes emerged as frames for nursing care: providing surveillance, soothing, being present, trading information, maintaining security and reducing.

Conclusions. These themes are used to strike a balance between turbulence and stability and to achieve equilibrium. As the nursing care intervenes when turbulence emerges, the PICU becomes a sanctuary that offers tranquility, peace and rest.

The objectives of the study are to report the 20-week base rate of violent behaviour in the community among a general psychiatric patient population from Stockholm and to establish the validity of a violence risk assessment software program, Classification of Violence Risk (COVR), in a European setting. Three hundred and thirty one patients at two psychiatric hospitals in Stockholm were interviewed upon discharge. Telephone interviews with the patients and collaterals were conducted 10 and 20 weeks later. The violent behaviour was also measured through a national criminal register. The allocation of patients into different risk groups according to COVR software was compared with the occurrence of actual acts of violence during the follow-up. The base rate of violent behaviour was 5.7% and a ROC-analysis showed that the AUC for COVR was 0.77. Since there were few patients in the high risk groups, the 95% confidence interval for the proportion of violent patients was wide. The base rate of violent behaviour is relatively low in Sweden and prediction is therefore difficult. The predictive validity of COVR software is comparable to other risk assessment tools.

Background: The literature on recidivism by homicide offenders is scarce despite its importance for individuals and for society.

Aims: To establish the rate of seriously violent re-offending among homicide offenders and identify risk factors for such recidivism.

Methods: A 1970s incident cohort of all homicide offenders, sane and insane, from two regions of Sweden (N=153) was followed up until 2007 using data from the national crime register.

Results: Ten per cent of the cohort (n=15) re-offended. The mean time from index offence to recidivism was 9.4 years. Five people (3%) committed a further homicide, and it was established that another five (3%) offenders had killed before the index offence. Prospective risk factors for violent recidivism were young age, psychotic disorder, male victim, acquainted victim and intoxicated victim.

Conclusions: The prevalence of repeated homicide is higher than previously reported. Victim variables and mental disorder in conjunction with substance abuse appear to be two domains of particular significance for recidivism.